Ship specimens to:

HENRY FORD CENTER for PRECISION DIAGNOSTICS Henry Ford Center for Precision Diagnostics Henry Ford Hospital 313.916.4DNA (4362) Pathology and Laboratory Medicine Toll Free: 855.916.4DNA Clinic Building, K6, Core Lab, E-655 Fax: 313.916.7071 2799 W. Grand Blvd. | Detroit, MI 48202 www.henryford.com/hfcpd HEREDITARY CANCER GENETIC RISK TESTING FORM Part I Please submit Clinical History Form (Part IIA or B)

Required Patient Information Ordering Physician Information

Name: ______Gender: M F Name: ______

MRN: ______DOB: ______MM / ______DD / ______YY Address: ______

Insurance Authorization #: ______City: ______State: ______Zip: ______ICD-10 Codes are required for billing. When ordering tests for which reimbursement will be sought, order only those tests that are medically necessary for the diagnosis and treatment of the patient. Phone: ______Fax: ______

Specimen Collection Date: ______Genetic Counselor: ______

ICD10 Code(s): ______/ ______/ ______Genetic Counselor Phone #: ______

Clinical Diagnosis: ______

This request to order tests from HFCPD certifies to HFCPD that (1) the ordering physician has obtained written informed consent from the patient as required by applicable state or federal laws for each test ordered and (2) the ordering physician has authorization from the patient permitting HFCPD to report results for each test ordered to the ordering physician.

I have been counseled on the risks and benefits of this testing and give my consent for this testing. Patient Signature: ______

I certify that this testing is medically necessary. Clinician Signature: ______

All tests include pathologist interpretation at a separate charge (G0452) Specimens Submission Requirements: Peripheral blood in lavender top tube (EDTA) Minimum Volume Requirements: 3 mL Specimen Stability: Ambient – 72 hours; Refrigerated – 1 week. Reasons for Rejection: Frozen specimen Submit Part IIA with this request. BRCA Mutation Testing q BRCA1 and BRCA2 (BReast CAncer genes 1 and 2) Sequencing and Common Deletions/ Duplications (CPT 81211) – 1st Tier Testing: includes full gene sequencing of BRCA1/2, with 5 common deletion/duplication by MLPA q BRCA1 and BRCA2 (BReast CAncer genes 1 and 2) Sequencing and Full Deletions/ Duplications (CPT 81162) – 2nd Tier Comprehensive Testing: includes full gene sequencing of BRCA1 and 2, with full gene (all exons) deletion/duplication by MLPA q BRCA1 and BRCA2 (BReast CAncer genes 1 and 2) Full Deletion/ Duplication by MLPA (CPT 81406) q Hereditary Breast/ Ovarian Cancer-Related Gene Sequence Analysis (19 genes) and Full Deletions/ Duplications (CPT 81432) – Tier 3 Testing: includes full gene sequencing of the following: ATM, BRCA1, BRCA2, BRIP1, CDH1, CHEK2, EPCAM, FANCC, MLH1, MSH2, MSH6, NBN, PALB2, PMS2, PTEN, RAD51C, RAD51D, STK11, TP53 – Testing DOES NOT include deletion/duplication analysis. q Other Deletions / Duplications: ______

Submit Part IIB with this request. Additional Hereditary Cancer Risk Mutation Testing – (May require prior Genetic counseling) q Hereditary Colorectal/ HNPCC Cancer Risk Panel (15 genes) and Full Deletions/ Duplications (CPT 81435): APC, ATM, BMPR1A, CDH1, CHEK2, EPCAM, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, SMAD4, STK11, TP53 q Hereditary Endometrial Cancer Risk Panel (18 genes) and Full Deletions/ Duplications (CPT 81321, 81317, 81292 and 81298): ATM, BRCA1, BRCA2, CHEK2, CDH1, EPCAM, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, STK11, TP53, BRIP1, NBN, PALB2, RAD51C q Hereditary Familial Cutaneous Melanoma Risk Panel (2 genes) and Full Deletions/ Duplications (CPT 81403, 81404): CDK4, CDKN2A q Hereditary Neuroendocrine Tumor Disorders Risk Panel (13 genes) and Full Deletions/ Duplications (CPT 81437): FH, MAX, MEN1, NF1, RET, SDHAF2, SDHB, SDHC, SDHD, TMEM127, TSC1, TSC2, VHL Submit Part IIB with this request. Customized Hereditary Cancer Testing (single or multi-gene panel, please specify). CPT codes vary by gene. Contact us for pricing on your custom panel. q AIP q BMPR1A q CDH1 q CHEK2 q EPCAM q EXT2 q FANCE q FH q KIT q MSH6 q PALB2 q PTCH1 q RET q SDHC q SUFU q WRN q ALK q BRCA1 q CDK4 q CYLD q ERCC2 q EZH2 q FANCF q FLCN q MAX q MUTYH q PHOX2B q PTEN q RHBDF2 q SDHD q TMEM127 q WT1 q APC q BRCA2 q CDKN1C q DDB2 q ERCC3 q FANCA q FANCGq GATA2 q MEN1 q NBN q PMS1 q RAD51C q RUNX1 q SLX4 q TP53 q XPA q ATM q BRIP1 q CDKN2A q DICER1 q ERCC4 q FANCB q FANCI q GPC3 q MET q NF1 q PMS2 q RAD51D q SBDS q SMAD4 q TSC1 q XPC q BAP1 q BUB1B q CEBPA q DIS3L2 q ERCC5 q FANCC q FANCL q HNF1A q MLH1 q NF2 q PRF1 q RB1 q SDHAF2 q SMARCB1 q TSC2 q BLM q CDC73 q CEP57 q EGFR q EXT1 q FANCD2 q FANCMq HRAS q MSH2 q NSD1 q PRKAR1A q RECQL4 q SDHB q STK11 q VHL

REV. 03.22.17 HENRY FORD CENTER for PRECISION DIAGNOSTICS HENRY FORD CENTER for PRECISION DIAGNOSTICS 313.916.4DNA (4362) Toll Free: 855.916.4DNA Fax: 313.916.7071 www.henryford.com/hfcpd CLINICAL HISTORY FOR HEREDITARY BREAST CANCER (HBOC) TESTING Part IIA

THIS IS NOT A TEST REQUEST FORM The information below is required to perform hereditary cancer testing. Please complete this form to the best of your ability and submit together with the Hereditary Cancer Genetic Risk Testing form (Part I).

Required Patient Information Ordering Physician Information

Name: ______Gender: M F Name: ______

MRN: ______DOB: ______MM / ______DD / ______YY Address: ______

Insurance Authorization #: ______Physician’s Specialty: ______

Patient’s primary language if not English: ______Physician’s Signature: ______

Patient’s Contact Number: ______Genetic Counselor: ______

Patient’s email Address: ______Genetic Counselor Phone #: ______

Patient’s ETHNICITY (check all that apply) q African American q Caucasian q Native American ex: African American, Ethiopian, Haitian, Jamaican, etc. ex: English, French, German, Irish, Italian, Polish, etc. ex: Aztec, Inuit, Lakota, Navajo, Mayan, Purhepecha, etc. q Ashkenazi Jewish q Hispanic, Latino, or Spanish origin q Native Hawaiian or Other Pacific Islander ex: Colombian, Cuban, Mexican/Mexican American, etc. ex: Chamorro, Fijian, Marshallese, Native Hawaiian, etc. q Asian q Middle Eastern or North African q Other: ex: Asian Indian, Chinese, Filipino, Japanese, Korean, etc. ex: Algerian, Egyptian, Iranian, Lebanese, Syrian, etc. ______

Is there a known mutation in the family? q Yes q No Specify family member name and relationship Gene: ______Mutation: ______Include lab report and/or testing facility if possible.

Is there a personal history of cancer in the patient? q Yes q No

Specify type(s): ______Age at Diagnosis: ______type(s): ______Age at Diagnosis: ______

Is there a personal or family history of the following HBOC cancer types? Please check all that apply: q Breast q Skin (melanoma) For each cancer type checked, please specify: q Bilateral q Lateral q Diffuse Gastric Cancer Type Relationship Age at Diagnosis q Triple negative q Adrenal Cancer q Ovarian q Sarcoma q Bilateral q Lateral q Brain tumor q Fallopian q Leukemia q Bilateral q Lateral q Thyroid Cancer q Uterine q Kidney Cancer q Pancreatic q Colon Cancer q Prostate (Gleason >7) q Other: ______

REV. 03.15.17 HENRY FORD CENTER for PRECISION DIAGNOSTICS HENRY FORD CENTER for PRECISION DIAGNOSTICS 313.916.4DNA (4362) Toll Free: 855.916.4DNA Fax: 313.916.7071 www.henryford.com/hfcpd CLINICAL HISTORY FOR HEREDITARY CANCER TESTING Part IIB

THIS IS NOT A TEST REQUEST FORM The information below is required to perform hereditary cancer testing. Please complete this form to the best of your ability and submit together with the Hereditary Cancer Genetic Risk Testing form (Part I).

Required Patient Information Ordering Physician Information

Name: ______Gender: M F Name: ______

MRN: ______DOB: ______MM / ______DD / ______YY Address: ______

Insurance Authorization #: ______Physician’s Specialty: ______

Patient’s primary language if not English: ______Physician’s Signature: ______

Patient’s Contact Number: ______Genetic Counselor: ______

Patient’s email Address: ______Genetic Counselor Phone #: ______

Patient’s ETHNICITY (check all that apply) q African American q Caucasian q Native American ex: African American, Ethiopian, Haitian, Jamaican, etc. ex: English, French, German, Irish, Italian, Polish, etc. ex: Aztec, Inuit, Lakota, Navajo, Mayan, Purhepecha, etc. q Ashkenazi Jewish q Hispanic, Latino, or Spanish origin q Native Hawaiian or Other Pacific Islander ex: Colombian, Cuban, Mexican/Mexican American, etc. ex: Chamorro, Fijian, Marshallese, Native Hawaiian, etc. q Asian q Middle Eastern or North African q Other: ex: Asian Indian, Chinese, Filipino, Japanese, Korean, etc. ex: Algerian, Egyptian, Iranian, Lebanese, Syrian, etc. ______

Is there a known mutation in the family? q Yes q No Specify family member name and relationship Gene: ______Mutation: ______Include lab report and/or testing facility if possible.

Is there a personal history of cancer in the patient? q Yes q No

Specify type(s): ______Age at Diagnosis: ______type(s): ______Age at Diagnosis: ______

Is there a personal or family history of the following cancer types? Please check all that apply: q Colorectal q Leukemia For each cancer type checked, please specify: q Lynch (MSI) q Diffuse Gastric Cancer Type Relationship Age at Diagnosis q Other: ______q Adrenal Cancer q Breast q Medullary thyroid q Bilateral q Lateral q Nonmedullary thyroid q Ovarian q Parathyroid q Bilateral q Lateral q Pheochromocytoma q Endometrial q Pituitary Cancer q Pancreatic q Kidney Cancer q Prostate q Other: ______

REV. 03.15.17 HENRY FORD CENTER for PRECISION DIAGNOSTICS